Clinical Care Classification System

"The Clinical Care Classification (CCC) System (...) provides a standardized framework and a unique coding structure for assessing, documenting, and classifying patient care by nurses and other clinical professionals in any health care setting. The CCC system consists of two interrelated terminologies: CCC of Nursing Diagnoses consists of 176 (60 major & 116 subcategories). CCC of Nursing Interventions/Actions consists of 804 Concepts (201 Core Interventions [77 major & 124 subcategories)]. The two terminologies are both classified by 21 Care Components that represent the Functional, Health Behavioral, Physiological, and Psychological Patterns of Patient Care. (...) The coding structure for the two terminologies is based on the ICD-10 (International Statistical Classification of Diseases and Health-Related Problems, 1990) consisting of five alphanumeric characters for information exchange among health care terminologies promoting interoperability. They are used to track and measure patient/client care holistically over time, across settings, population groups, and geographic locations. (...) The CCC System is recognized as the terminology of choice for documenting the essence of patient care in the electronic health record (EHR) systems. It meets all the features of a concept-oriented terminology and has been formally accepted by the various standards organizations. (...) The CCC System is being used to document nursing care in the electronic health record (EHR) computer-based patient record (CPR) and Personal Health Record (PHR) Systems. It serves as a language for nursing and other health care providers such as physical, occupational, and speech therapists, medical social workers, etc."